Published - Thu, 23 Feb 2023

NCLEX-PN Exam Questions - Part 45

1. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

A) grief work facilitation
B) vital signs monitoring
C) medication administration: skin
D) anxiety reduction

2. The nurse should teach a client in the Emergency Department, who has suffered an ankle sprain, to:

A) use cold applications to the sprain during the first 24 - 48 hours.
B) expect disability to decrease within the first 24 hours of injury.
C) expect pain to decrease within 3 hours after injury.
D) begin progressive passive and active range of motion exercises immediately.

3. Jane Love, a 35-year old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?

A) anemia
B) edema
C) painless vaginal bleeding
D) fatigue

4. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?

A) perineal shave
B) enema
C) urine specimen collection
D) blood specimen collection

5. Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissas complaints with which of the following statements?

A) 'The physician will probably want to admit you for observation.'
B) 'The physician will probably order bed rest at home.'
C) 'These are really dangerous signs.'
D) 'The physician will probably prescribe some medicine for you.'

1. Right Answer: A
Explanation: Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution. Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns. Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns. Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns. Health Promotion and Maintenance

2. Right Answer: A
Explanation: Cold applications are believed to produce vasoconstriction and reduce development of edema. Disability and pain are anticipated to increase during the first 23 hours after injury. Progressive passive and active exercises may begin in 25 days, according to the physicians recommendation. A sprain is a traumatic injury to the tendons, muscles, or ligaments around a joint, characterized by pain, swelling, and discoloration of the skin over the joint. The duration and severity of the symptoms vary with the extent of damage to the supporting tissues.Treatment requires support, rest, and alternating cold and heat. X-ray pictures are often indicated to be certain that no fracture has occurred.PhysiologicalAdaptation

3. Right Answer: C
Explanation: Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. The abdomen might be soft, nontender, and relax between contractions. Physiological Adaptation

4. Right Answer: B
Explanation: An enema could dislodge the placenta and increase bleeding. Physiological Adaptation

5. Right Answer: B
Explanation: Pregnancy-induced hypertension (PIH) is a hypertensive disorder of pregnancy, developing after 20 weeks gestation. It is characterized by edema, hypertension, and proteinuria (preclampsia and eclampsia). The cause is unknown. The client with advanced PIH needs rest, and home is the best place to get it. Hospitalization is not necessary in this situation. Medication is not indicated. Physiological Adaptation

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